'Oath Betrayed' Questions Doctors' Roles in TortureIn the spring of 2004, when Americans were horrified by the pictures of abuse at Iraq's Abu Ghraib prison, medical-ethics expert Steven Miles had just one question: Where were the doctors? Miles, himself a doctor, has written a book about how the medical profession failed to perform its role as protector.

Dr. Steven Miles is a professor of medicine at the University of Minnesota Medical School and a faculty member of its Center for Bioethics. Scroll down to read an excerpt from Miles' book, Oath Betrayed.
Tim Rummelhoff
hide caption

toggle caption

Tim Rummelhoff

Book Excerpt: 'Oath Betrayed'

June 28, 20064:48 PM ET

Detail from Dilawar's two death certificates.
From 'Oath Betrayed' (Random House)
hide caption

Dilawar was a twenty-two-year-old farmer and taxi driver, whom American soldiers tortured to death over five days at Bagram Collection Point in Afghanistan in December 2002. When the soldiers pulled a sandbag over his head, Dilawar complained that he could not breathe. He was then shackled and suspended from his arms for hours, denied water, and beaten so severely that his legs would have been amputated had he survived. When he was beaten with a baton, he would cry "Allah, Allah!," which guards found so amusing that they beat him some more just to hear him cry. During his final interrogation, soldiers told the delirious, injured prisoner that he would get medical attention after the session. Instead, he was returned to a cell and chained to the ceiling. Several hours later, a physician found him dead. By then, the interrogators had concluded that Dilawar was innocent and had simply been picked up after driving his new taxi by the wrong place at the wrong time.

Dilawar's death was predictable and preventable. The counterintelligence team was inexperienced; only two of its thirteen soldiers had ever conducted interrogations before arriving in Afghanistan. The officers knew that President Bush and Secretary Rumsfeld had ruled that the Geneva Conventions did not apply to Afghanistan. The interrogation policies were unclear. The base commander had ignored Red Cross protests about the treatment of prisoners, including the practice of suspending them. Army and intelligence officers who knew of the ongoing pattern of abuses at the Bagram facility did not intervene to stop them. In fact, another prisoner, Habibullah, had died at the same facility under similar circumstances six days before Dilawar's death.

An autopsy on December 13 found that Dilawar's death was a homicide, caused by extensive and severe "blunt force injuries to lower extremities complicating coronary artery disease" (inexplicably, "coronary artery disease" is typed on the death certificate in a different font). The Pentagon reported that the prisoner died of natural causes. Later, a coroner testified that Dilawar's legs were "pulpified" and that the body looked as if it had been "run over by a truck." Soldiers delivered the body and an English-language death certificate to his wife and two daughters in January 2003. The family could not read English.

In February, General Daniel McNeil, the commander of U.S. forces in Afghanistan, told reporters that Dilawar died of natural causes and that 85 percent of his coronary artery was obstructed. He said that he had "no indication" that Dilawar had been injured in prison; later, he said that the prisoner had been injured before arriving at Bagram and went on to assert, "We are not chaining people to the ceilings." General Daniel McNeil was evidently familiar with Dilawar's autopsy, which had found that a coronary artery was 70 percent to 80 percent occluded even though that heart disease did not cause his death. The Office of the Armed Forces Medical Examiner, which had done the autopsy, did not contradict General McNeil's statements and did not release the death certificate or autopsy report.

Later in February, reporters went to Dilawar's village and located his family, who had the copy of the death certificate stating that Dilawar had died of homicidal injuries. The reporters confronted General McNeil with the death certificate that had been given to the family and asked him to explain why he had told reporters that Dilawar died a natural death of heart disease. General McNeil said that he always gave press the "best information available to him."

Dilawar has two or three death certificates. The family's certificate, finalized on December 13, 2002, fills in a box captioned "Circumstances Surrounding Death Due to External Causes" with "Decedent was found unresponsive in his cell while in custody." A year and a half after the death, the Pentagon released another death certificate, finalized on May 20, 2004, that does not describe the circumstances in which the body was found. The Defense Department released yet another death certificate in April 2005. That document, dated December 2002, may be the one given to the family. It includes the description of the death's discovery and adds Dilawar's age and religion, but omits the date of death and changes the title and address of the pathologist.

Dilawar is not the only prisoner who died a violent death for whom there exists more than one death certificate. The Pentagon has released two differing death certificates for Fahin Ali Gumaa, who died of multiple gunshot wounds. One certificate was finalized May 21, 2004, just before a Pentagon press conference, and the other was finalized June 2, 2004, after the press conference. The usual rule for death certificates is "one per customer."

Army criminal investigators waited sixteen months to begin investigating Dilawar's death. They found probable cause to charge twenty-seven soldiers with various roles in causing and concealing the death, including a charge of withholding medical care. No one was charged with murder. Five of the fifteen who were prosecuted have pleaded guilty to assault and other crimes. The harshest punishment received was five months in a military prison. One soldier was convicted of maiming, assault, maltreatment, and making a false statement; he was demoted and honorably discharged. Dilawar left a widow and two-year-old daughter. One of his brothers, Shahpoor, reacted to the sentences this way: "I am angry with them, but this was the will of God. God is great, and God will punish them." Vice Admiral Church identified Dilawar's death as one in which medical personnel might have tried to conceal the abuse of a prisoner.

PRISONERS TORTURED TO DEATH

Nineteen prisoners are known to have died of beatings, asphyxiation, or being suspended by American soldiers or intelligence officials. These men died at Asadadad, Bagram, and Gardez in Afghanistan and at Abu Ghraib, Camp Bucca, Camp Whitehorse, Basra, Mosul, Tikrit, and another unidentified facility in Iraq.

The figure of nineteen deaths from torture does not include all prisoners whose deaths were homicides, or all prisoners who died by torture. It does not include criminal homicides that took place on the battlefield or in the interval between capture and imprisonment. It does not include prisoners who died of injuries wantonly inflicted by Afghan or Iraqi soldiers working with U.S. forces, even when such a badly beaten prisoner was turned over to U.S. authorities before dying in U.S. custody. It does not include homicides by torture that were committed by British soldiers, such as the deaths of Baha Mousa and Kifah Taha, listed in the table at the end of this chapter. It undoubtedly fails to include some homicides of "ghost prisoners," such as Al-Jamadi, whose death was described in the preceding chapter—people who were secretly imprisoned by U.S. intelligence agencies. It does not include homicides among the deaths that were not investigated or that were only superficially investigated, or where the investigations were preempted by base commanders. It does not include cases where a homicide was misattributed to natural causes. It does not include homicides among the prisoners who have likely died after U.S. authorities sent them to be interrogated in torturing countries such as Uzbekistan. It does not include at least twenty "justified" shootings of "rioting" prisoners. (For example, in September 2003, a Red Cross observer witnessed a guard shooting a Camp Bucca prisoner through the chest and wrote: "The shooting showed a clear disregard for human life and security of the persons deprived of their liberty." The Army concluded that the shooting was justifiable. Major General Antonio Taguba, who conducted the Army's first investigation of the Abu Ghraib scandal, noted similar incidents. It does not include prisoners who died of medical neglect or after being needlessly and illegally exposed to mortar and sniper attacks on prisons. A map of the topography of "substantiated" criminal homicides, justified homicides, and unsubstantiated-as-homicide prisoners' deaths looks like this.

Substantiated criminal homicide (e.g., death from torture)

Substantiated justified homicide (e.g., shooting of rioting prisoner)

Homicide unsubstantiated because of obstructed investigation (e.g., local commander obstructs investigation, or prisoner dies after rendition to a torturing country, or unregistered prisoner dies in small base prison, or unregistered prisoner dies in intelligence agency custody)

The Armed Forces Institute of Pathology is responsible for determining the cause of death of a prisoner in U.S. facilities in Iraq, in Afghanistan, and at Guantánamo Bay. In 1996, it created the Office of the Armed Forces Medical Examiner (AFME) to conduct autopsies of soldiers and civilians (including prisoners) who died while in the armed forces or under their jurisdiction. In 2002, budget cutbacks left the AFME with only two forensic pathologists; by 2004, it had thirteen.

Armed forces medical examiners' autopsy reports and death certificates as well as Army and Navy criminal investigation reports show that pathologists often did not seem to have been given information ordinarily available to pathologists. A pathologist bases a determination of cause of death on more than an autopsy. An autopsy, or necropsy, entails inspecting and dissecting a body, examining organs, performing toxicology and chemical tests, and looking at tissues with a microscope or sometimes with X rays. The pathologist correlates the autopsy findings with information from medical records, accounts of the events preceding the death, and a description of the circumstances in which the body was found. As noted in the preceding chapter on interrogations, preinterrogation and postinterrogation medical examinations, if conducted at all, were kept in classified intelligence files separate from regular medical records. Chapter 5, "Neglect," will show that even these regular medical records were haphazardly kept and often lost in Iraq and Afghanistan. Even when clinical records and death scene descriptions existed, pathologists' and field investigators' reports show mostly one-way communication between forensic pathologists and Army or Navy criminal investigators. Pathologists performed autopsies and forwarded their findings and death certificates to investigators who did the event analysis. In other words, the pathologists often had to determine the cause of death without on-site investigative findings. For example, the physical findings at autopsy of a person who dies of suffocation, a common cause of death among recognized prisoner homicides, can be very subtle. A pathologist must know whether the prisoner had a hood over his head or was gagged, suspended, or bound in a manner that could prevent the chest from expanding and the victim from inhaling. Information to include or exclude such possibilities is absent from many of the autopsy reports.

The Office of the Armed Forces Medical Examiner was inadequately prepared to investigate deaths of prisoners who may have died of torture. Its pathologists had published little on forensic pathology. They were not known for having special expertise in investigating or documenting the injuries of persons who died under torture. There is no evidence that they used a special protocol for conducting autopsies on prisoners who may have died from torture. It does not even appear that they were familiar with protocols such as the "Manual on the Investigation of Torture and Other Cruel, Inhuman, or Degrading Treatment," a guide, endorsed by the UN and the World Medical Association, for physicians who examine bodies for signs of death by torture.21 That manual recommends that pathologists inspect bodies for signs of beatings, thermal and chemical burns, visible and invisible fractures, signs of the use of tight ligatures around the penis or extremities, suffocation, brain damage, suspension tears to ligaments or muscles or nerves, and anal or vaginal penetration. The AFME autopsies often failed to look for injuries to bones or ligaments or for signs of sexual abuse. For example, Mr. Al-Jamadi (discussed in Chapter 3) died while being suspended by his arms, which had been tied together and lifted up behind his back. Witnesses reported that his shoulders were twisted and protruding out of their sockets, but the pathologist did not even record an examination of the shoulders for dislocation or for tearing of the ligaments and nerves of the upper arms.